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Abstract：
BACKGROUND: India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme\'s design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation.
METHODS: Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state\'s population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem.
RESULTS: Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure.
CONCLUSIONS: AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.
METHODS: Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state\'s population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem.
RESULTS: Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure.
CONCLUSIONS: AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.
摘要：
背景：印度于2018年启动了一项名为AyushmanBharatPradhanMantriJanArogyaYojana（AB-PMJAY）的国家健康保险计划，作为全民健康覆盖的关键政策。这项雄心勃勃的计划覆盖了1亿贫困家庭。没有一项研究检查了其对护理质量的影响。关于AB-PMJAY对财务保护的影响的现有研究仅限于其实施的早期经验。从那以后,政府已改善计划的设计。当前的研究旨在评估AB-PMJAY对提高利用率的影响，质量,以及实施四年后对住院护理的财务保护。
方法：2021年和2022年在恰蒂斯加尔邦进行了两次年度家庭调查。调查有一个代表该州人口的样本，覆盖约15,000个人。根据患者满意度和住院时间来衡量质量。财政保护是通过不同阈值的灾难性卫生支出指标来衡量的。多变量调整模型和倾向得分匹配用于检查AB-PMJAY的影响。此外,使用工具变量法来解决选择问题。
结果：参加AB-PMJAY与提高住院护理利用率无关。在AB-PMJAY注册的使用私人医院的个人中，在2021年和2022年，发生灾难性卫生支出占年度消费支出10%的比例分别为78.1%和70.9%。无论AB-PMJAY的覆盖范围如何，私立医院的使用都与更大的灾难性支出有关。AB-PMJAY下的登记与自费支出或灾难性卫生支出的减少无关。
结论：AB-PMJAY已经实现了很大的人口覆盖率，但在实施四年后，医院报销价格以证据为基础的上涨，它没有对提高利用率产生影响，质量,或金融保护。根据该计划签约的私家医院继续向病人收取过高的费用,购买在调节提供者行为方面是无效的。建议进行进一步研究，以评估公共资助的健康保险计划对其他低收入和中等收入国家的财务保护的影响。
方法：2021年和2022年在恰蒂斯加尔邦进行了两次年度家庭调查。调查有一个代表该州人口的样本，覆盖约15,000个人。根据患者满意度和住院时间来衡量质量。财政保护是通过不同阈值的灾难性卫生支出指标来衡量的。多变量调整模型和倾向得分匹配用于检查AB-PMJAY的影响。此外,使用工具变量法来解决选择问题。
结果：参加AB-PMJAY与提高住院护理利用率无关。在AB-PMJAY注册的使用私人医院的个人中，在2021年和2022年，发生灾难性卫生支出占年度消费支出10%的比例分别为78.1%和70.9%。无论AB-PMJAY的覆盖范围如何，私立医院的使用都与更大的灾难性支出有关。AB-PMJAY下的登记与自费支出或灾难性卫生支出的减少无关。
结论：AB-PMJAY已经实现了很大的人口覆盖率，但在实施四年后，医院报销价格以证据为基础的上涨，它没有对提高利用率产生影响，质量,或金融保护。根据该计划签约的私家医院继续向病人收取过高的费用,购买在调节提供者行为方面是无效的。建议进行进一步研究，以评估公共资助的健康保险计划对其他低收入和中等收入国家的财务保护的影响。
